Medical Cooperation Between Iraqis and Israelis: Mitigating Crisis Through Partnership
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In an unprecedented webinar organized by the Center for Peace Communications, Iraqi physician Sarmad Sadiq and Israeli physician Eli Karniel discussed potential medical cooperation between Iraq and Israel. The webinar participants parsed the many challenges facing Iraq’s collapsing healthcare sector in contrast to Israel’s success in the field and emergence as one of the best healthcare providers in the world. Despite the recent decision by Iraq’s parliament to criminalize normalization with Israel, the participants agreed on the need for cooperation, highlighting the benefits Iraq would gain from using advanced Israeli medical technology. This brave call for engagement should be championed by the United States, which should support concrete steps to transfer both medical technology and expertise to Iraq from Israel through joint ventures in the medical field. It should also protect such enterprises from an assault by pro-Iranian factions as part of its own involvement as a partner.
Understanding the Problem
Over the past two years, the COVID-19 pandemic heightened pressures on health care sectors around the world. Among the many countries ill-prepared to meet the challenge was Iraq. Though a leader in the region’s medical services as recently as the 1970s, its system had deteriorated over decades and now suffered from endemic corruption, scant human and financial resources, and a breakdown in trust between doctors and patients.
Nearby Israel, by contrast, had emerged as a leading provider of healthcare services, its system hailed as one of the best in the world and its medical research and innovation hubs a source of breakthroughs. The country’s effective management of the pandemic and success in implementing a nationwide vaccination campaign served as a global model.
To discuss the problems facing Iraq’s healthcare system and potential remedies available through cooperation with Israelis in the field, the Center for Peace Communications convened an unprecedented webinar on May 11, 2022, bringing together Iraqi and Israeli physicians in their respective countries: Dr. Sarmad Sadiq, Head of the Department of Plastic Surgery in Erbil International Hospital, Vice President of the Kurdistan Society of Plastic Surgery, and a practicing plastic surgeon in Erbil and Baghdad; and Dr. Eli Karniel, Deputy Manager of Internal Medicine Ward B at the Meir Medical Center in Israel.
The timing of the discussion proved poignant. On the same day in Baghdad, the Sadrist bloc in Iraq’s parliament joined the Speaker to introduce a new “anti-normalization law,” binding on Iraqis globally, which prescribes death or life imprisonment for the slightest contact with an Israeli citizen. (The legislation passed 15 days later.) Yet Dr. Sarmad saw no cause for delay, stressing that his encounter with Dr. Karniel was not ahead of its time but rather late in coming. The case for forging working ties between the two countries’ health sectors is a humanitarian imperative, the two agreed, which should override the ideological impositions of any faction within Iraq. They proceeded to envision concrete steps to bring doctors and medical specialists from the two countries together, urging international support for their plan.
Iraq’s Healthcare Crisis
As a 2021 report in Fikra Forum observes, Iraq’s once-reliable healthcare sector has been declining for decades, amid a cascade of crises owing to the country’s war with Iran, the embargo imposed on Iraq following its invasion of Kuwait, and “the Saddam Hussein regime’s manipulation of the oil-for food program.” Efforts following the 2003 U.S.-led invasion to improve the healthcare system largely failed due to corruption, which grew over successive political parties’ domination of the Health Ministry. As a research paper by the Konrad Adenauer Foundation in 2021 concludes,
[P]olitical parties in control of the healthcare system compromise the safety and efficacy of both public and private hospitals by systematically evading quality controls and maximizing profits from medical supply chains at all costs … [E]merging political parties and their armed wings took full control of the public procurement process for medical devices, pharmaceuticals, and facility maintenance, in addition to the growing private medical market. Today, public contracts are awarded to businesses with close ties to the political entities controlling the Ministry of Health. Profits are often inflated either by overvaluing the contract or under-delivering the service, product, or both. The parties and their affiliates maximize profits by evading the kinds of quality controls and safety standards that prevent fires.
Aside from corruption, a further factor in the deterioration of Iraqi healthcare relates to the lack of skilled doctors. As Dr. Sarmad noted, doctors in Iraq “make just $700 to $800 per month on average, and many seek second jobs in the private sector to supplement their low income.” Others have simply left, he said — a migration which began in the 1990s and has continued ever since. According to a Reuters study, “in 2018, Iraq had just 2.1 nurses and midwives per thousand people, less than Jordan’s 3.2 and Lebanon’s 3.7, according to each country’s estimates. And it had just 0.83 doctors per thousand people, far fewer than its Middle Eastern counterparts. Neighboring Jordan, for example, has 2.3 doctors per thousand.”
The study puts the number of doctors who have left the country since the 1990s at nearly forty percent of the total. Dr. Sarmad added that there are not enough doctors to train medical students, who consequently miss basic medical knowledge and expertise. This problem has contributed, in turn, to the paucity of post-graduation medical training and general lack of sub-specialization among doctors.
Broader Iraqi government neglect of the healthcare system “has also had a demonstrably negative impact on the country’s health infrastructure. Health centers suffer from chronic shortages of medical supplies and resources.” This neglect has resulted in a severe decline in the number of hospital beds per person, which have “decreased between 1980 and 2017, from 1.9 beds for every 1,000 to just 1.3.” Alaa Alwan, a former Minister of Health, lamented, “Health is not a priority and the indicators show that. The government did not give healthcare what it deserves.” The Reuters report on Iraq’s healthcare system paints a dark image of Iraqi hospitals:
Six beds are crammed into each room and every bed is occupied. With just 1.2 hospital beds per 1,000 people, Iraq lags the region. Mothers sleep on the floor, beside their sick children. Fathers sleep in an adjacent trailer – Iraqis call it a caravan. Even the emergency rooms have been repurposed to accommodate more patients. Administrators say the hospital may soon have to expand into storage sites.
Government rules regarding medicine procurement are also to blame, with doctors barred “from purchasing equipment or medicine from the private sector.” As one Iraqi doctor put it, “If he played by the books, kids would simply die.”
The result of this catastrophic state has been “increased patients’ and families’ frustration with the medical system,” which in turn has led to doctors being “attacked by patients’ families, who are angry with what they see as unsatisfactory care.” As a doctor told Reuters, “When someone dies, we call the police first, before we tell the family, just in case.” For others, the result is simply to travel abroad. As the Konrad Adenauer Foundation study notes, “Iraqi patients distrustful of both private and public options in Iraq often sell homes, properties, and cars to seek treatment in neighboring countries.”
Israel’s Medical Sector
Like Iraq, Israel has a universal healthcare system, but the World Index of Healthcare Innovation ranks it fifth worldwide. A Commonwealth Fund report notes, “Israel provides … universal coverage to citizens and permanent residents as part of its national health insurance law. Residents choose from four competing nonprofit health plans that provide a mandated benefit package, including hospital, primary, specialty, mental health, and maternity care, as well as prescription drugs and other services.” During the webinar, Dr. Sarmad said, “This is what I need for my country as well.”
In his discussion with Karniel, Dr. Sarmad evinced curiosity about Israel’s system for maintaining medical standards: comparative quality data for individual health plans is made public, the Ministry of Health releases hospital-specific metrics, and both nursing homes and mother-and-child clinics receive equivalent scrutiny. He also inquired about the country’s substantial medical innovation sector, which comprises 1,200 companies in life sciences, medical equipment, bio-pharma, medical computing, and services. Among the solutions they provide to challenges faced internationally — notably, home-based care, early diagnosis, and preventive medicine — one of them, ultrasound technology, is Dr. Karniel’s area of focus. “Ultrasound specifically … has the potential to change the daily practice very fast and also it is an extremely cheap technology,” Karniel said. Contrasting ultrasound with more costly medical technology, he said, “If you want to have a proton radiation center you need close to $100 million just to establish it and maintain it. If you want to have a hundred or two hundred more CT scanners all over Iraq, you also need about $2 million just per one station before we get into maintenance and so on.” Israeli ultrasound technology, both inexpensive and easily transported, is already in use in countries facing health sector challenges similar to Iraq’s, Karniel said, including remote parts of Central America.
The Potential for Collaboration
Between the dire need in Iraq and availability of expertise and advanced medical technology in Israel, the webinar participants discussed possible means of collaboration. They agreed that neither politics nor ideology should obstruct partnerships to save lives. “Dr. Karniel and I share a common point of view,” Sarmad said. “When it comes to the life of a patient or taking care of a patient, doctors observe no boundaries.” Asked about Israeli enthusiasm for engaging Iraqi peers, Dr. Karniel said, “I think the answer is a plain yes. Since we began discussing these matters, I have also spoken to colleagues and asked whether they would be willing to come and teach, and no one hesitated.”
Karniel envisioned a partnership whereby Israeli medical institutions provide training to Iraqi doctors, whether through virtual encounters or gatherings in a third country. “Of course, practically speaking, we cannot come to Iraq and Iraqis cannot come to Israel at the moment,” he said, “but we can definitely meet on mutual ground and set that kind of cooperation.” Dr. Sarmad called for doing so “to give a push to the health sector in Iraq, because otherwise we’re going to be blaming ourselves, and the generations that follow ours will blame us for not doing anything.” Dr. Eli concurred: “Even without having any special preparations, we can definitely start and teach a few hundred doctors in the next year and really start a nice little revolution in terms of what the patient at the end gets a year from now, even in a remote village in Iraq. We can definitely do that.”
Sarmad suggested a further form of cooperation: transfer medical knowledge and experience through pairings of hospitals in the two countries. “Some sort of joint venture along these lines will enormously benefit surgeons and other doctors in Iraq, at a time when we need to improve our health sector because we have bled a lot.” He suggested that as Iraq was formerly home to a vibrant Jewish community, it would be natural to reopen the door to Israeli doctors of Iraqi descent who wish to help the country recover its lost capacities.
As to the technical side, Karniel and Sarmad agreed that the low-cost, ready available portable ultrasound devices, enhanced by artificial intelligence applications Israel has developed, should be transferred to Iraqi doctors and hospitals as an easy means to substantially upgrade the quality of diagnosis and, by extension, treatment.
Such potential cooperation can draw inspiration from Israeli-UAE cooperation in the medical field. Numerous Israeli med-tech companies now operate in the UAE, including the medical software company ezMedSoft; Healthy.io, which transforms the smartphone camera into a medical device; and MediWound, a biopharmaceutical company that develops novel biotherapeutic solutions for tissue repair and regeneration.” The two countries have also signed a number of agreements for cooperation in the medical sector that cover the fields of digital medicine, protection of medical data, and use of artificial intelligence. These agreements create the framework for the exchange of medical experts and development of joint ventures in the medical field. Crucially, the two countries have signed further agreements for the exchange of doctors and medical knowledge. Sheba Medical Center, for example, reached terms with Dubai-based Al Tadawi Healthcare Group for Israeli doctors to conduct face-to-face diagnostic consultations with diabetes patients in the UAE. military and police, as well as send physicians to train medical personnel at Medcare Women & Children Hospital in Dubai.
The U.S. Role
Since 2014, the United States has provided more than $3 billion in humanitarian assistance to Iraq and its people in the broader region, making it Iraq’s largest humanitarian donor. In 2021, the State Department announced nearly $155 million in further humanitarian assistance for essential healthcare and to boost the capacity of health care facilities.” While this assistance is admirable, systemic corruption in Iraq virtually guarantees that officials and political parties will siphon off much of the aid. Both the Iraqi government and Ministry of Health face accusations of selling medicine intended for the Ministry on the black market. Nor would proposed attempts to privatize the health sector address the problem, according to the Konrad Adenauer Foundation study, as “both private and public medical facilities are subject to the same [political] forces.”
Thus the U.S. faces the familiar question of how to ensure that its assistance truly reaches its intended beneficiaries. Part of the answer may lie in underwriting the type of knowledge transfer and low-cost medical equipment supply which the Iraqi-Israeli webinar participants call for. Support for medical education and training through virtual learning programs offers an impactful form of aid which the Iraqi political class cannot easily loot. The small size of Israel’s low-cost ultrasound technology, for its part, allows for varying delivery channels and strategies as a means to prevent theft of the equipment.
As to some Iraqi factions’ attempt to block such cooperation through draconian “anti-normalization laws,” U.S. policymakers have called for a range of measures to deter the law’s enforcement, through a combination of pressure on the one hand and engagement with Iraq’s caretaker government on the other. The U.S. can work to ensure that Israeli assistance to Iraq’s health sector proceeds safely by becoming a partner in the endeavor. Its role can include the brokering of assurances of non-molestation by Iraqi officials. Doing so not only advances the health and well-being of Iraqi citizens; it also enables a demonstration of the tangible benefit of Iraqi-Israeli partnership and the folly of standing in its way.